Sexation

2. Pediatric Procedural
Sedation
Dr. Marc N. Francis
MD, FRCPC
University of Calgary
Foothills Medical Centre
Alberta Children’s Hospital

3. Disclosure
I do not have an affiliation (financial or otherwise) with
any commercial organization that may have a direct or
indirect connection to the content of my presentation.

4. PSA in the ED
 “Painful procedures are unavoidable in emergency
medicine”
 “While anesthesiologists have unique qualifications to
provide sedation, their availability is variable and
unreliable, and is limited by commitments to the
operating room”
Procedural Sedation and Analgesia in the Emergency Department.
Canadian Consensus Guidelines
Journal of Emergency Medicine 1999; 17(1): 145-156

5. Learning Objectives
 “Tools of the Trade”
 Sedation medications that you should know well and be familiar with
 “The Right Tool for the Job”
 Discuss the variable needs for procedural sedation in the ED and
pharmaceutical options
 “Tricks of the Trade”
 Some adjuncts and techniques that will make your job easier
 Controversies
 A look at some of the more controversial aspects of procedural
sedation in children
 The Future
 What is coming down the pipe for the future of procedural sedation

7. Importance
 Studies have shown that children are less likely than
adults to receive pain medications and sedation for
similar painful procedures*
 Children cannot fully understand the medical necessity for
testing or therapeutics
 Children’s anxiety can heighten the discomfort
 Allows for control of behaviour for the safe and successful
completion of a procedure
 Parental, patient and physician satisfaction
*Selbst SM Analgesic use in the Emergency Department. Ann Emerg Med 1990;19:1010-1013

8. Sedation Spectrum
 Minimal Sedation
 Patient responds appropriately to verbal commands
 Cognitive processing affected but no cardiopulmonary effects
 Moderate Sedation
 Patient responds to verbal commands or with addition of mild
stimulus
 Maintains airway and ventilation without required intervention
 Deep Sedation
 Not easily aroused but responds purposefully with uncomfortable
stimulus
 May require medical intervention to maintain an airway and
ventilation
 General Anesthesia
 Unable to be aroused with a verbal or painful stimulus
 Need help maintaining their airway

9. Indications for Pediatric Procedural
Sedation
 Diagnostic
 Urinary Catheterization
 Lumbar puncture
 Radiographic evaluation
(CT or MRI)
 Joint aspiration
 Sexual assault
examinations
 Eye examinations
 Therapeutic
 IV starts
 Laceration repair
 Abscess I+D
 Fracture Reductions
 Dislocations reduction
 Foreign body removal
 Burn dressings

10. The Search Continues…
 The ideal sedation protocol:
1) Rapid induction and emergence
2) Provides anxiolysis, analgesia and amnesia
3) Sufficient control of movement to allow for ease
of procedural completion
4) Maintain effective spontaneous ventilation and
airway control
5) Complete Cardiopulmonary stability throughout
6) Minimal to no side effects

11. “Tools of the Trade”

12. Nitrous Oxide
 Dissociative gas with
mild to moderate
procedural anxiolysis,
analgesia and amnesia
 Dosage
 50% concentration
blended with oxygen
 Ideally self administered
 Advantages
 Onset and offset within 5mins
 Does not require an IV
 Disadvantages
 Requires special delivery device
 Nausea and Vomiting
 Well ventilated room with
scavenger system

13. Midazolam
 Short-acting agent with
rapid onset of anxiolysis,
sedative and amnestic
properties
 Interacts with GABA
receptors in the brain
 Dosage
 0.2-0.6mg/kg intranasally
 0.05-0.2mg/kg IV
 0.1-0.2mg/kg IM
 0.5-0.75mg/kg PO
 Advantages
 Rapid onset
 Anxiolysis
 Profound retrograde amnesia
 No IV required
 Disadvantages
 Does not provide analgesia
 Disturbance in respiratory
function +/- hypoxemia
 Paradoxical reactions

14. Fentanyl
 Synthetic opiod which is
narcotic of choice in PSA
 Rapid onset and short
duration make it easy to titrate
 Does not cause histamine
release so minimal CV effects
 Dosage
 1-3mcg/kg IM or IV
 10-20mcg/kg oral or
transmucosal
 Advantages
 Excellent analgesic
 Peak effect within 15-30mins
 Reversible with naloxone
 Disadvantages
 Nausea and vomiting
 Respiratory depression
 Hypotension
 No amnesia. Minimal sedation
 Fentanyl Rigid Chest

15. Ketamine
 Dissociative agent
 Sedation, analgesia and
amnesia are maintained
 Inhibits reuptake of
catecholamines
 Stimulates salivary, tracheal
and bronchial secretions
 Dosage
 1-2mg/kg IV
 2-5mg/kg IM
 6-10mg/kg PO
 Disadvantages
 Emergence phenomenon
 Nausea and Vomiting
 Increased secretions
 Potentially serious respiratory
complications
 Advantages
 Reliably produces potent
analgesia, sedation and amnesia
 Hemodynamic stability
 Maintain airway reflexes

16. Propofol
 Potent hypnotic agent
with no analgesic
properties
 Effects lipid membrane
Na-channel function and
Stimulates GABA
 Rapid onset,
redistribution and
elimination
 Dosage
 1mg/kg IV bolus then
0.5mg/kg q45-60sec
 Advantages
 Rapid onset/offset
 Easily titratable
 Anti-emetic
 Bronchodilator
 Disadvantages
 No analgesic properties
 Potent cardiopulmonary
depressant
 Pain on injection
 Inadvertent oversedation

17. “The Right Tool for
the Job”

18. The Right tool for the Job
 28mth ♀ presents with 4day hx of
fever, vomiting and flank pain
 PMHX – Healthy
 Temp 38.5, HR 121, RR 16,
BP 84/56, Sat 98% RA
 Not toilet trained
 Wanting to do an in/out cath
 Nitrous Oxide
 Midazolam
 Fentanyl
 Ketamine
 Propofol
Sedation Spectrum:
Minimal Sedation

19. The Right tool for the Job
 5yo ♂ fell onto wooden post
 Extensive and complex facial
laceration requiring multilayer
closure
 PMHX – Asthma well controlled
 VSSA
 Nitrous Oxide
 Midazolam
 Fentanyl
 Ketamine
 Propofol
Sedation Spectrum:
Dissociative
Sedation

20. The Right tool for the Job
 15yo ♂ playing soccer and collided
with another player
 Immediate pain to R shoulder which
is clinically consistent with anterior
dislocation
 Very Anxious!!!
 PMHX – Healthy
 Normal Vital signs
 Nitrous Oxide
 Midazolam
 Fentanyl
 Ketamine
 Propofol
Sedation Spectrum:
Moderate Sedation

21. The Right tool for the Job
 7yo ♀ presents with patellar
dislocation while playing softball
 Knee in “spasm” and patient
extremely anxious with any attempts
to examine or maneuver same
 PMHx – Healthy
 VSSA
 Nitrous Oxide
 Midazolam
 Fentanyl
 Ketamine
 Propofol
Sedation Spectrum:
Minimal Sedation

22. The Right tool for the Job
 3yo ♂ fell off the bed and refusing
to walk
 Xray shows a displaced spiral tibial
fracture
 PMHx – seizure disorder well
controlled
 VSSA
 Nitrous Oxide
 Midazolam
 Fentanyl
 Ketamine
 Propofol
Sedation Spectrum:
Dissociative
Sedation

23. “Tricks of the Trade”

24. Ondansetron with
Ketamine Sedation
 Vomiting in the ED and upon discharge after
Ketamine sedation is common
 Reported frequency of vomiting ranges from 4-19%
 Increased vomiting associated with increasing
patient age
 Vomiting
 Decreases patient and parental satisfaction
 Delays discharge and consumes ED resources

25.  Double-blind, randomized, placebo-controlled trial
 N= 255 children randomized to
 N= 128 IV Ondansetron 0.15mg/kg to max 4mg
 N = 127 Placebo
 Results
 ED vomiting was less common with ondansetron 4.7% vs
12.6% p=0.02
 NNT of 13
 Vomiting in the ED or after discharge was less frequent with
ondansetron 7.8% vs 18.9% p=0.01
 NNT of 9

26. Pre-oxygenation with
procedural sedation
 Published adverse event rates during pediatric ED
procedural sedation vary between 2% and 18%
 Consistently the most common adverse event is
transient hypoxia
 Children’s basal oxygen use/kg is twice that of adults
 Smaller FRC
 Shorter “safe apnea” period before desaturation
 Transient hypoxia is predictably seen with propofol
 Very common with Midazolam and Fentanyl
 Less likely with Ketamine unless co-administration with other resp
depressants

27. Adjunctive Atropine with
Ketamine Sedation
 Ketamine stimulates oral secretions
 In rare circumstances this has been implicated in
airway compromise1
 Historically prophylactic anticholinergic agents
have been given with ketamine to blunt
hypersalivation
 Glycopyrrolate 0.2mg
 Atropine 0.02mg/kg

28.  Prospective observational study of ED pediatric
patients receiving ketamine sedation
 N= 1090 patients over a 3yr period
 947 (87%) were performed without adjunctive atropine
 Assessed for salivation on a 100mm visual analog scale and
documented complications
 Results
 92% of patients had salivation rated at 0mm or “none”
 Only 1.3% were rated >50mm
 Transient airway complications in 3.2% of which only one
was thought to be related to hypersalivation (incidence 0.11%
95% CI 0.003% - 0.59%)
 No occurrence of assisted ventilation or intubation

29. Adjunctive Atropine with Ketamine
Sedation
 Omission of atropine is safe
 Routine prophylaxis is unnecessary
 There is minimal added risk presented with its
administration
 Possible subsets of patients which may benefit
 Very young children
 Those undergoing oropharyngeal procedures

30. Controversies

31. In your local ED….
 9yo M previously healthy with no meds/allergies
 Fell mountain biking 40mins ago and has
deformed and partially angulated radius/ulnar #
 Neurovascularly intact distally
 Wearing helmet and no issues with potential HI
 Bag of chips 2hrs ago with bottle of Gatorade
 Survey
 Would you sedate this child now?
 What would you use?

32. Pre-sedation Fasting guidelines
 Minimal scientific evidence to support fasting
 Risk of aspiration during ED PSA has not been
studied
 Only single case of pulmonary aspiration with ED
sedation has been reported
Cheung K, et al. 2007. Ann Emerg Med 2007;49:462-464
 Extrapolation from general anesthesia literature
 Incidence of aspiration is low (1:3,420)
 Mortality is rare (1:125,109)

33. Relative risk of aspiration
 Good reason to believe that aspiration risk with
PSA may be lower than GA
 2/3 of aspiration occurs during airway manipulation
 Deeper level of sedation with GA
 Generally younger and healthier patients (ASA I-II)
 Inhalational agents are more emetogenic
 Ketamine sedation preserves protective airway
reflexes

34. What we are told
CAEP
 No specific guidelines
 “Insufficient data to show
that fasting improves
outcomes in patients
undergoing ED
procedural sedation”
 In elective situations
consider NPO x 2hrs
(liquids) and 6hrs (solids)
ACEP
 No specific guidelines
 “No study has determined
a necessary fasting period
before initiation of PSA”
 “Recent food intake is not
a contraindication for
PSA but should be
considered in choosing
the timing and target of
sedation”

35.  ED specific clinical practice advisory
 Goal to create a tool to permit ED physician to identify prudent
limits of sedation depth and timing in light of fasting status
 Developed a 4-step assessment prior to sedation
1) Asses patient risk
2) Assess the timing and nature of recent oral intake
3) Assess the urgency of the procedure
4) Determine the prudent limit of targeted depth and
length of procedural sedation and analgesia

36. Assess Patient risk
 Difficult airway?
 High risk for esophageal reflux?
 Esophageal disease
 Hiatal hernia
 PUD
 Bowel obstruction
 Extremes of age?
 >70
 <6mths
 Severe Systemic disease?
 ASA ≥ III

37. Timing and nature of oral intake
 Single time point for sake of simplicity = 3hrs
 From lowest to highest theoretical risk
1) Nothing
2) Clear liquids
3) Light snack
4) Heavier snack or meal

38. Urgency of the procedure
 Emergency
 Cardioversion for life threatening arrythmia
 Reduction of markedly angulated fracture
 Urgent
 Care of dirty wounds and lacerations
 Abscess I+D
 Semiurgent
 Care of clean wounds and lacerations
 Shoulder reduction
 Nonurgent or elective
 Foreign body in external ear canal
 Ingrown toenail

39. Depth of sedation
 Procedure Duration
 Brief: <10mins
 Intermediate: 10-20mins
 Extended: >20mins

40. Standard-risk patient

41. Higher-risk Patient

42. Capnography monitoring during
procedural sedation
 Non-invasive
measurement of the
partial pressure of CO2
from the airway during
inspiration and
expiration

43. Capnography monitoring
 Traditional monitoring
 Pulse oximetry = oxygenation
 RR and clinical observation = ventilation
 Capnography
 More precise and direct assessment of the patient’s
ventilatory status
 Assessment of airway patency and respiratory pattern
 Early warning system for prehypoxic respiratory depression
 Assessment of depth of sedation

45. Show me the evidence!!!
 Comparison of oximetry, capnography and clinical
observation in the ED2
 75% of pediatric patients with respiratory compromise were
noted by EtCO2 monitoring only
 Pediatric RCT comparing capnography to clinical
observation in detecting resp events3
 Clinical assessment identified hypoventilation in 3% and did
not identify any patients with apnea
 Capnography data showed ventilation was compromised in
>50% of cases and nearly 25% fulfilled criteria for apnea

46. Recommendations
 Good evidence that capnography provides a
means for early detection of sedation-related
hypoventilation
 Clinical significance with regards to improved
patient outcomes has not been shown

48. Future
“where we’re going we don’t
need roads” – Dr. Emmett Brown

49. Ketofol
Propofol
 Pros
 Antinauseant effects
 Amnestic
 Smooth recovery profile
 Cons
 Cardiovascular and
respiratory depression
 Bradycardia
 Non-analgesic
Ketamine
 Pros
 Analgesia
 Amnesia
 Respiratory and
cardiovascular stability
 Cons
 Emergence phenomena
 Vomiting

50.  Prospective case series
 114 ED procedural
sedations
 1:1 mixture of ketamine
10mg/ml and propofol
10mg/ml
 All age groups including
children as young as 4
 Results
 97% success rate with
procedures
 3 patients with transient
hypoxia
 1 required BVM
 3 patients with emergence
 No hypotension or
vomiting
 Patient satisfaction scores
were 10 on a 1-10 scale

51.  Systematic review of the literature
 8 clinical trials were included
 Adult and pediatric studies were included
 Results
 Ketofol was not superior to propofol monotherapy
 Conflicting data exist regarding hemodynamic and respiratory
complications
 At higher doses addition of ketamine to propofol may incur
more adverse effects
 Compatability data for the two agents combined in a syringe
are limited

52. Ketofol
 Theoretical benefits that have not been demonstrated
in the literature
 Optimum ratio of ketamine and propofol remains to be
determined
 Dosing regiments currently are highly variable
Not ready for
Primetime………….Yet

53. BIS

54. Bispectral Index
 BIS
 Uses processed EEG
signals to measure the
depth of sedation
 Validated with children
undergoing general
anesthesia in the OR

55.  Determine if the BIS monitor could be used to
guide physicians in titrating propofol for safe
levels of deep sedation in children
 Results
 BIS score of 45 determined to provide deep sedation
for 95% of the population
 Useful objective tool to guide effective titration of
propofol for children

56. Conclusions
 Familiarize yourself with your pharmaceutical options
and “pick the right tool for the job”
 Pre-oxygenation is your friend
 Atropine is out and ondansetron is in for routine
ketamine sedations
 Pre-procedural fasting guidelines are not black-and-
white and each situation is unique
 Consider the additional information provided by
capnography if it is available to you
 Ketofol not ready for primetime….. yet

57. Questions?

58. Additional References
1) Green SM et al. Intramuscular ketamine for pediatric sedation
in the emergency department: safety profile with 1022 cases.
Ann Emerg Med. 1998;31:688-97
2) Hart LS et al. The value of end-tidal CO2 monitoring when
comparing three methods of conscious sedation in children
undergoing painful procedures in the emergency department.
Pediatr Emerg Care 1997;13(3):189-93
3) Lightdale JR et al. Microstream capnography improves patient
monitoring during moderate sedation: a randomized, controlled
trial. Pediatrics 2006;117(6):e1170-8
4) Lopez MD et al. Pediatric Procedural Sedation. Emergency
Medicine Reports 2008;13(12):145-156

59. Additional Slides

60. Fentanyl Rigid Chest
 Believed to be due to a central agonist effect of
narcotics
 The pediatric population is more vulnerable to the
syndrome
 Reported with doses from 2.5-6.5mcg/kg
 Difficulty in ventilating is largely due to upper airway
(glottis) closure
 Not thoracoabdominal tone as originally thought
 In kids thoracoabdominal tone plays a larger role

61. Prevention of Fentanyl Rigid Chest

62. Propofol epilepsy

63. Is Propofol a pro- or anticonvulsant?
 81 reported cases of presumed propofol induced
seizure like activity
 Agonist-antagonist effect on Glycine which is a major
inhibitory neurotransmitter

64.  Prospective study
 Effects of IV propofol on EEG
 25 children with epilepsy
 25 children with learning disorders
 Undergoing elective sedation for MRI

65.  Results
 No child in either group had increased spike-wave
pattern with propofol
 Depression in spike-wave pattern in the children
with epilepsy was seen
 Supported the concept of propofol being a
sedative-hypnotic agent with anticonvulsant
properties

66. Aspiration case in
literature

67.  65yoF with HTN
 Trimalleolar fracture
 Morphine/fentanyl/Propofol for first PSA with
no significant complications
 Second PSA in attempt to improve the
reduction
 6hrs after last meal
 Propofol/fentanyl
 10 mins after propofol bolus the patient
vomited into the mask and aspirated

68.  Sats were 86% initially
 Airway was suctioned and BVM was started with
improvement to sats 97%
 Patient remained hypoxic with sats 84% on RA
 Inspiratory and expiratory wheezes throughout
 RSI was performed and admitted to ICU where
she was ventilated for 12hrs then slowly weaned
 No long-term complications

69. Etomidate

70. Etomidate
 Initially described for RSI in peds
 Rapid onset of sedation, brief half-life, short recovery
period and minimal effects on cardiopulmonary
systems
 Adverse effects
 Potential for adrenal suppression
 Pain at injection site
 Myoclonus
 Quickly and easily induce deep sedation and/or general
anesthesia.
 More studied for PSA in the adult population in United
States

71.  Only randomized control trial evaluating etomidate for
pediatric PSA in the ED
 Randomized double-blind study out of Montreal
 N=100 patients 2-18yo
 50 = IV Etomidate 0.2mg/kg + Fentanyl 1mcg/kg
 50 = IV Midazolam 0.1mg/kg + Fentanyl 1mcg/kg
 Outcomes
 Induction and recovery times
 Efficacy of sedation
 Adverse event rates

72.  Results
 Time taken for induction and recovery were lower
among those receiving etomidate
 Success rates were not different
 Adverse event rates were similar with the exception
of
 Pain at injection site 46% vs 12%
 Myoclonus 22% vs 0%

73. Etomidate
 Need a large series to better establish the safety
profile of etomidate for PSA in pediatrics
 A randomized trial comparing etomidate,
propofol and ketamine would be of great
interest…..
Any takers?

74. Propofol infusion
syndrome

75. Propofol Infusion Syndrome
 1992 case reports of fatalities
 High and escalating doses of propofol infusions
 Severe metabolic acidosis, lipidemia, rhabdo and
refractory heart failure
 Associated with long-term infusions >48hrs in
children <4yo
 Thought to be related to a mitochondrial defect
 Not an issue for brief ED sedation

76. Preoxygenation
protocol

77. Pre-oxygenation with
procedural sedation
 Published adverse event rates during pediatric ED
procedural sedation vary between 2% and 18%
 Consistently the most common adverse event is
transient hypoxia
 Children’s basal oxygen use/kg is twice that of adults
 Smaller FRC
 Shorter “safe apnea” period before desaturation
 Transient hypoxia is predictably seen with propofol
 Very common with Midazolam and Fentanyl
 Less likely with Ketamine unless co-administration with other resp
depressants

78.  1244 procedural
sedations
 Median age
5.9yrs
 Complications
in 17.9%
 No
preoxygenation
protocol